Provider Demographics
NPI:1841484110
Name:GANLEY, KATHLEEN M (PT)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:M
Last Name:GANLEY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 EASCOTT PL STE 100
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29229-7586
Mailing Address - Country:US
Mailing Address - Phone:803-720-5240
Mailing Address - Fax:803-736-9406
Practice Address - Street 1:212 EASCOTT PL
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29229-7586
Practice Address - Country:US
Practice Address - Phone:803-586-7126
Practice Address - Fax:803-736-9406
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-30
Last Update Date:2019-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5346225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCTH1844Medicaid